Telemedicine is an extension of eHealth defined as the use of new and emerging technology to enhance health and health care.1 Two other frequently used terms associated with telemedicine are telecare and telemonitoring, the latter representing distant monitoring of patients in their home environment. Telemedicine represents an exciting shift in the delivery of health care, a shift that will transition patient care from the physician’s office or clinic into the patient’s home. On a regional level, it will allow urban providers to reach rural areas. Specific to COPD, telemedicine within the last decade has demonstrated its ability to reduce emergency department visits and hospitalizations and to detect early the exacerbation of COPD.2
COPD, a chronic condition that affects 210 million people worldwide and is responsible for 3 million deaths yearly, is a target for diverse methods of management aimed at improving quality of life and lowering the cost of care.3 Chronic diseases including cardiovascular disease, diabetes, COPD, and many more represent 46% of the burden of disease worldwide. In the United States alone, 78% of health care costs are associated with the treatment of chronic disease.2 In fact, chronic conditions are such a burden on health delivery systems that they have become a focal point for public health efforts and remain one of public health’s highest priorities in reducing the overall burden of disease. Over the last century, public health has seen a transition in disease demographics from infectious disease to chronic diseases now bearing the greater burden. Considering the prevalence of COPD, the use of effective and alternative modalities of care could have a drastic impact on health improvement and its associated costs.
The burden of chronic disease is multifaceted and includes personal and societal burdens that generate stress on patients, their family members, and their social networks. COPD is an irreversible lung disease characterized by non-fully reversible bronchoconstriction, a disease that requires close monitoring, medication adherence, and socio-behavioral changes in order to reduce symptoms and maximize the patient’s ability to function daily. For COPD, telemedicine could offer health care providers greater flexibility in the delivery of care, along with improvements in patient monitoring to help prevent COPD exacerbations. Do not be mistaken, telemedicine is not a means for replacing health care providers in the delivery of care. Instead, it is a powerful tool that holds great potential by augmenting care, improving patient outcomes, and increasing the quality of life for those with COPD.
THE POTENTIAL FOR TELEMEDICINE TO IMPROVE ACCESS TO CARE
Currently, the demand for health care is on the rise and increasing at an uncontrollable rate. Who would have thought 30 to 40 years ago that health care would become much like a traditional business, with health care professionals using such terms as “supply and demand” along with “shortage”? Today, there is a supply and demand problem facing health care—the demand is up and the supply is down. There is currently, and will remain until about the year 2030, a shortage of health care workers to meet the demand for care. This warrants a change in the delivery of health care and may indeed alter the way individuals and populations receive health care. Telemedicine holds great potential in reaching out to those who are isolated by where they live (geographic isolation) or by how many others they live around (demographic isolation). For example, an individual or even an entire small community 300 miles away from the closest tertiary hospital is geographically isolated and has limited access to specialty services. In regard to demographic isolation, individuals living in a metropolis close to tertiary centers may be limited in their ability to seek specialty services due to an overwhelming demand by a large population. Telemedicine holds the promise of being able to provide services to each population with the use of technology in the fields of both health care and communications.
Telemedicine: For COPD, interventions with a dedicated COPD case manager have reduced the number of exacerbations and hospital admissions
For those in remote regions of any state or province, videoconferencing and distant consultation could be used to provide care over very large distances. Regarding care over large distances, it was ruled by law that if providers were to provide care within a particular state’s boundaries, they would have to have a license within that jurisdiction. The Centers for Medicare and Medicaid Services (CMS) has recognized the importance of telemedicine and its potential for improving access to care and reducing costs. The Centers’ release in the May 5, 2011 edition of the Federal Register states: “This final rule reflects the Centers for Medicare and Medicaid Services’ commitment to the general principles of the President’s Executive Order released January 18, 2011 [titled] ‘Improving Regulation and Regulatory Review.'”4 The response by Medicare to this executive order was the down-regulating of providers and critical access hospitals (CAHs) in the privileging process for physicians and lower level practitioners who provide telemedicine services. Essentially, this new final rule allows physician privileges at one Medicare participating hospital to be recognized at another Medicare participating hospital when telemedicine services are provided. This is a major step toward regional cooperation among hospitals that initially felt bound by federal regulations pertaining to physician privileging and the ability to provide care outside of the hospital walls. This supportive action by CMS has reduced red tape and paved an easier path to providing care to rural areas, thus stimulating outreach programs and cooperation among health care institutions, and promotes a more regional approach to care with the formation of health care systems. Even more encouraging, hospitals within a region can form cooperatives and still remain independent of one another, maintaining their local identity and commitment to the communities that they have served for years and will continue to serve with improved access.
THE COST OF CARE
Considering that COPD is an irreversible chronic illness, its management has been focused on symptom relief provided by medication regimes and the use of supplemental oxygen. Despite all efforts, it remains a leading cause of death, particularly in developed nations.5 Reducing symptoms and preventing exacerbation are difficult and may be achieved to a higher degree with the use of telemonitoring. The popularity of COPD as a target for the reduction of cost has grown due to its alarming increase in both prevalence and incidence throughout the world.5 With more and more individuals being diagnosed with COPD and many others most likely undiagnosed, managing this disease will be ever more important to improving health and reducing cost. In 2000, the total annual cost of COPD had increased by 30%, reaching $31 billion, and in 2004, the cost was $37.2 billion. For patients with mild COPD, the average annual cost was $1,618, and severe COPD averaged $10,812.5 Two studies by Micheletto et al in 1994 and again by Agha et al in 2002 demonstrated a reduction in cost for the management of COPD with the use of telemedicine.6,7 The cost savings were most notable in a cohort of patients who were using supplemental oxygen and receiving home care assistance for 6 years or more. This population may be more vulnerable to exacerbation and hospitalization, and detecting early symptoms of exacerbation might prevent hospitalization and therefore reduce direct costs. The cost savings that telemedicine has demonstrated over the last 10 to 20 years has renewed an interest in its use by both health delivery systems and large payors such as Medicare and Medicaid. Despite the potential to reduce costs and improve access to care, there remain barriers to its implementation.
THE IMPACT ON PROVIDERS AND PATIENTS
The delay in the use of telemedicine or telehealthcare in the United States revolved around reimbursement. Just as soon as insurance companies recognized its benefit and began to offer payment for telemedical services, interest in its use increased.8 Nurses and respiratory therapists, as front line providers within the hospital and within the home setting, might feel threatened by aspects of telemedicine and, more specifically, telemonitoring. Let’s face it, we have all been in situations where change has been resisted simply because it is thought to be less effective or nontraditional, despite evidence that a new approach has great potential benefit. Health care and, more specifically, patient care are steeped in traditions based on direct patient interaction, touch, and emotion. Don’t be misled; telemedicine does not seek to remove the human element of care, but rather to be available more often than providers can afford in face of an ever-increasing demand for care. As an industry, health care and its providers need to embrace change that could ultimately improve patient access and patient security. Of the studies performed related to telemedicine and its implementation, the response from patients was very positive; most stated that they felt a strong sense of security with being monitored often and having access to the provider in a short period of time.9
For providers working in the home, most were satisfied with the technology, although there were feelings of detachment from the patient.9 This is a reasonable and expected response, but it should not deter the use of telemedicine simply because the traditional forms of care delivery are more satisfying. Inevitably, health care will experience an increasing demand. The current tone from providers indicates increasing stress, and telemedicine and telemonitoring may be able to relieve some of the burden placed on providers. For example, in the home care setting, patients may be visited twice per week, especially the sickest. If telemonitoring were used, it could be that only one visitation per week would be necessary. Equipment that would gather vital signs data three times per day and daily subjective input from the patient might present a stable situation that does not require a home visitation. This makes additional time available for providers to spend with other patients who may need the extra attention. Wanting to provide personal individualized care to every patient on service is a great expectation; however, visitations may not always be possible, and telemedicine in these instances may add a sense of security to both the patient and the provider. Patients could be triaged based on disease, severity, history, and clinical data; priorities assigned to each; and a visitation schedule designed that serves the sickest of patients and monitors others for signs of trouble. Telemedicine is unorthodox, requiring a change in clinical practice and a deviation from the norm. However, until a more formidable health work force can be assembled, it is an option that deserves great consideration. For respiratory therapists, it may not be unreasonable that they would be positioned within pulmonologists’ offices and monitoring data that uploads from home monitors, and they may also intercept videoconferencing calls from patients who are experiencing difficulty. It is safe to say that a respiratory therapist may be the most appropriate allied health professional for the assessment of patients with pulmonary disease, especially those patients presenting with an exacerbation of COPD or any other chronic lung disease.
ICU TELEMEDICINE—NOW AND THE FUTURE
Holding great value is the use of specialists in the treatment of some of our sickest and most complex patients receiving care in intensive care units across the country. Today, only 30% of ICU patients are cared for by a dedicated specialist: the intensivist. Care of critically ill patients by an intensivist results in lower mortality and reduced length of stay. Despite their expertise and value, not all hospitals have access to this specialty service. Telemedicine is an answer for many institutions with the use of videoconferencing and intranet systems that allow for direct secure connections between off-site intensivists and the more rural ICU. This “real time” care can allow for rapid assessment and treatment of life-threatening changes in a patient’s condition. Currently, it is estimated that 10% of American ICUs have tele-ICU coverage.10 Studies on tele-ICU care present encouraging results, indicating that 83% of respondents felt that the system enhanced the quality of care. Even more encouraging, prior to implementation, only 67% of providers felt that the tele-ICU would facilitate collaboration with intensivists, compared to 94% post-implementation. This only reasserts a major point that change is often difficult to accept and imagine, but in many instances, the result can prove to be positive.
Open minds and innovative thinking will aid the health care system in meeting the demands of an ever-growing population that is experiencing an eye-opening growth in chronic illness. In regard to COPD, respiratory therapists are apt to see a change in the delivery of care to their most sick patients. How we as a profession respond to the use of telemedicine will define our future role and involvement in patient care.
Michael T. Provencher, MPH, RRT, is a clinical coordinator for the Department of Respiratory Care and Paul F. Nuccio, MS, RRT, FAARC, is the director of pulmonary services, both at Brigham and Women’s Hospital, Boston. For further information, contact [email protected]
- Evers K. eHealth promotion: the use of the Internet for health promotion. Am J Health Promot. 2006;20(4):suppl 1-7, iii.
- Pare G, Jaana M, Sicotte C. Systematic review of home telemonitoring for chronic diseases: the evidence base.J Am Med Inform Assoc. 2007;14:269-77.
- World Health Organization. Chronic Obstructive Pulmonary Disease (COPD). Available at: www.who.int/respiratory/copd/en/index.html Accessed May 10, 2011.
- Changes affecting hospital and critical access hospital conditions of participation: telemedicine credentialing and privileging. Fed Regist. 2011;76:25550-25565. To be codified at CFR Part 482 and 485.
- Negro RD. Optimizing economic outcomes in the management of COPD. International Journal of COPD. 2008;3:1-10.
- Micheletto C, Pomari C, Righetti P. A two-year health economics survey on 61 subjects in telemetric LTOT: preliminary results. Eur Resp J. 1994;7:266.
- Agha Z, Schapira RM, Maker AH. Cost effectiveness of telemedicine for the delivery of outpatient pulmonary care to a rural population. Telemed J E Health 2002;8:281-291.
- McLean S, Protti D, Sheikh A. Telehealthcare for long term conditions. BMJ. 2011;342:d120.
- Mair F, Hiscock J, Beaton S. Understanding factors that inhibit or promote the utilization of telecare in chronic lung disease. Chronic Illn. 2008;4:110-7.
- Young L, Chan P, Cram P. Staff acceptance of tele-ICU coverage. Chest. 2011;139:279-88.